The Conundrum of Risky Painkillers for Veterans with PTSD

War veterans with severe pain may need drugs like morphine and hydrocodone to manage it, but the medications are associated with higher rates of overdose and self-harm in those with post-traumatic stress.

Veterans of the Iraq and Afghanistan war are more than twice as likely to be prescribed opioid medications, such as morphine and hydrocodone, for their physical pain if they also have post-traumatic stress disorder (PTSD). These soldiers are also more likely to overdose on drugs or alcohol, be involved in violence or self-harming behavior, including suicide, or have other accidents than veterans who do not use the pain relievers, according to a new study.

Researchers examined the records of nearly 16,000 veterans in treatment for pain-related problems at Department of Veterans Affairs hospitals and physicians’ offices. About 51% were diagnosed with some type of mental health disorder as well as pain, with 32% having PTSD either alone or in combination with another mental health condition like depression.

Overall, 11% of veterans received an opioid prescription for more than 20 days, which is long enough to develop physical dependence if the drugs are taken daily. The prescriptions were given to nearly 18% of vets with PTSD and 12% of those with other mental health problems, compared with just under 7% of those who did not have such disorders.

Veterans with a current or past diagnosis of an alcohol or other drug disorder were four times more likely to receive opioid painkillers than vets without addiction problems. While opioids are sometimes necessary for people in recovery and can be used safely if carefully monitored, 77% of the veterans in the study were prescribed opioids by general practitioners, many of whom are not well trained in dealing with complex cases of pain in people at high risk of addiction.

Of course, it’s not exactly surprising that people with past addictive disorders would seek these drugs, or that they might be able to get them from doctors when they also have a genuine pain condition resulting from a war wound.

But it’s also not clear what to do about the problem. The authors of the new study, led by Dr. Karen Seal, who treats patients at the San Francisco VA Medical Center, point out that earlier research shows that people with PTSD may experience greater physical pain: these patients have problems with their brain’s opioid systems, which is associated with “lower pain thresholds and lower endogenous opioid levels.” In other words, they suffer both more pain and a possible deficit of the brain’s natural painkillers.

Moreover, other studies show that the agony and intensity of both emotional and physical pain are processed by some of the same brain regions, and that depression and chronic pain are associated with dysfunction in these areas. These very regions have high levels of opioid receptors — the receptors in the brain on which opioid pain relievers work — at least normally.

Thus, some doctors may prescribe the medications for veterans in hopes of relieving both mental and physical suffering. This could account for the fact that veterans with PTSD are 42% more likely to receive the highest doses of opioids and five times more likely to be prescribed anti-anxiety medications that can increase overdose risk when combined with opioids, compared with vets without mental disorders, according to the study.

The overlap between mental and physical pain and the involvement of opioid system dysfunction in PTSD itself complicates the prescribing issue. There is very little data on how best to manage people whose pain can’t be addressed using non-opioid drugs, alternative treatments or physical and cognitive-behavioral therapies, particularly if they also have PTSD.

But this study shows that our current way of prescribing these drugs isn’t helping wounded warriors, since it is linked with greater risk for overdose, violence, accidents and self-injury. Whether the drugs themselves cause these problems, whether their prescription reflects more serious pain and PTSD, whether the PTSD itself pushes unsafe drug use, or some combination of all three is not clear.

The VA’s pain management policy allows for the use of opioid drugs in veterans, but only as part of a comprehensive pain care plan, in conjunction with nondrug treatment by mental health experts or other therapists, and only if other painkillers don’t work.

The authors conclude, “Extra care should be taken when prescribing opioids to relieve [veterans’] distress. These patients may benefit from biopsychosocial models of pain care including evidence-based nonpharmacologic therapies and nonopioid analgesics.”

Of course, it would be even better if PTSD itself could be prevented entirely. There is intriguing data that suggests, counterintuitively, that very early treatment with opioids could help prevent the development of the disorder in the first place, which would in turn eliminate the higher risks of addiction and excess pain associated with PTSD. For example, a study of veterans injured in combat published in 2010 in the New England Journal of Medicine found that receiving early treatment with opioids for an injury cut the patients’ risk of developing PTSD in half.

Two other studies of burns in children also found that the higher the dose of morphine they received early in treatment, the less likely they were to develop PTSD afterwards. Other research has suggested that marijuana-like substances could also be useful in PTSD prevention. To prevent later drug problems, then, might it be necessary to use the drugs we fear early on?

The research was published in the Journal of the American Medical Association.